The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion.

BACKGROUND: Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods. MAIN OUTCOMES AND MEASURES: The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64. RESULTS: Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries. CONCLUSIONS: Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

Perceived discrimination and mental health outcomes in college students: the mediating effect of preventive health behaviors and social support.

Objective: To examine the role of social support and health behaviors in the association between discrimination and mental health (e.g., anxiety/depressive symptoms, suicidal ideation) among college students experiencing various forms of discrimination. Participants: Data were collected from 709 college students (42.8% White; 72.2% female) at a large urban university in Fall 2017. Methods: Students completed an online survey assessing perceived discrimination, anxiety/depressive symptoms, suicidal behavior, health behaviors, and social support. Moderation and parallel mediation analyses were conducted in PROCESS SPSS. Results: Results indicated that preventive health behaviors and social support partially mediated associations between discrimination and mental health outcomes. Conclusions: Findings highlight the need to increase awareness regarding engaging in preventive health behaviors on college campuses. For students experiencing discrimination, prevention, and social support might be key factors in improving mental health.

Impact of performance-based budgeting on quality outcomes in U.S. military health care facilities.

BACKGROUND: Performance-based budgeting (PBB) is a variation of pay for performance that has been used in government hospitals but could be applicable to any integrated system. It works by increasing or decreasing funding based on preestablished performance thresholds, which incentivizes organizations to improve performance. In late 2006, the U.S. Army implemented a PBB program that tied hospital-level funding decisions to performance on key cost and quality-related metrics. PURPOSE: The aim of this study was to estimate the impact of PBB on quality improvement in U.S. Army health care facilities. APPROACH: This study used a retrospective difference-in-differences analysis of data from two Defense Health Agency data repositories. The merged data set encompassed administrative, demographic, and performance information about 428 military health care facilities. Facility-level performance data on quality indicators were compared between 187 Army PBB facilities and a comparison group of 241 non-PBB Navy and Air Force facilities before and after program implementation. RESULTS: The Army's PBB programs had a positive impact on quality performance. Relative to comparison facilities, facilities that participated in PBB programs increased performance for over half of the indicators under investigation. Furthermore, performance was either sustained or continued to improve over 5 years for five of the six performance indicators examined long term. CONCLUSION: Study findings indicate that PBB may be an effective policy mechanism for improving facility-level performance on quality indicators. PRACTICE IMPLICATIONS: This study adds to the extant literature on pay for performance by examining the specific case of PBB. It demonstrates that quality performance can be influenced internally through centralized budgeting processes. Though specific to military hospitals, the findings might have applicability to other public and private sector hospitals who wish to incentivize performance internally in their organizational subunits through centralized budgeting processes.

Addressing social risk factors in the inpatient setting: Initial findings from a screening and referral pilot at an urban safety-net academic medical center in Virginia, USA.

Social Determinants of Health (SDOH) impact health outcomes; thus, a pilot to screen for important SDOH domains (food, housing, and transportation) and address social needs in hospitalized patients was implemented in an urban safety-net academic medical center. This study describes the pilot implementation and examines patient characteristics associated with SDOH-related needs. An internal medicine unit was designated as a pilot site. Outreach workers approached eligible patients (n = 1,135) to complete the SDOH screening survey at time of admission with 54% (n = 615) completing the survey between May 2019 and July 2020. Data from patient screening survey and electronic health records were linked to allow for examination of associations between SDOH needs for food, housing, and transportation and various demographic and clinical characteristics of patients in multivariate logistic regression models. Of 615 screened patients, 45% screened positive for any need. Of 275 patients with needs, 33% reported needs in 2, and 34% - in 3 domains. Medicaid beneficiaries were more likely than patients with private health insurance to screen positive for 2 and 3 needs; Black patients were more likely than White patients to screen positive for 1 and 3 needs; Patients with no designated primary care physician status screened positive for 1 need; Patients with a history of substance use disorder screened positive for all 3 needs. SDOH screening assisted in addressing social risk factors of inpatients, informed their discharge plans and linkage to community resources. SDOH screening demonstrated significant correlations of positive screens with race/ethnicity, insurance type, and certain clinical characteristics.

Identifying Area-Level Disparities in Human Papillomavirus Vaccination Coverage Using Geospatial Analysis.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection within the United States (US). Despite clinical agreement on the effectiveness and widespread availability of the prophylactic HPV vaccine, vaccination coverage in the US is suboptimal and varies by geographic region and area-level variables. The goals of this article were to model the variation in vaccination rates among boys and girls within ZIP Codes in Virginia, determine whether neighborhood sociodemographic variables explain variation in HPV vaccination, and identify areas with significantly depressed vaccination coverage. METHODS: We used Bayesian hierarchical spatial regression models with statewide immunization registry data to consider the correlation in vaccination among boys and girls, as well as the spatial correlation in vaccination for each sex. RESULTS: The results showed low vaccination coverage in our birth cohort (28.9% in girls and 23.8% in boys) relative to the national level (56.8% and 51.8%, respectively). Several area-level variables were significantly and positively associated with vaccination coverage, including population density, percentage of Hispanic population, and average number of vehicles. In addition, there were several areas of significantly lowered vaccination coverage, including predominantly rural ones, and overall large geographic disparities in HPV vaccination. CONCLUSIONS: Determining the geospatial patterning and area-level factors associated with HPV vaccination within a prescribed geographic area helps to inform future planning efforts. IMPACT: The results of this study will help inform future planning efforts for geographically targeted interventions and policies, as well as drive new research to implement clinical and community strategies to increase HPV vaccination.

Health Insurance Coverage Mandates: Colorectal Cancer Screening in the Post-ACA Era.

Building a culture of precision public health requires research that includes health delivery model with innovative systems, health policies, and programs that support this vision. Health insurance mandates are effective mechanisms that many state policymakers use to increase the utilization of preventive health services, such as colorectal cancer screening. This study estimated the effects of health insurance mandate variations on colorectal cancer screening post Affordable Care Act (ACA) era. The study analyzed secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) and the NCI State Cancer Legislative Database (SCLD) from 1997 to 2014. BRFSS data were merged with SCLD data by state ID. The target population was U.S. adults, age 50 to 74, who lived in states where health insurance was mandated or nonmandated before and after the implementation of ACA. Using a difference-in-differences (DD) approach with a time-series analysis, we evaluated the effects of health insurance mandates on colorectal cancer screening status based on U.S. Preventive Services Task Force guidelines. The adjusted average marginal effects from the DD model indicate that health insurance mandates increased the probability of up-to-date screenings versus noncompliance by 2.8% points, suggesting that an estimated 2.37 million additional age-eligible persons would receive a screening with such health insurance mandates. Compliant participants' mean age was 65 years and 57% were women (n = 32,569). Our findings are robust for various model specifications. Health insurance mandates that lower out-of-pocket expenses constitute an effective approach to increase colorectal cancer screenings for the population, as a whole. PREVENTION RELEVANCE: The value added includes future health care reforms that increase access to preventive services, such as CRC screening, are likely with lower out-of-pocket costs and will increase the number of people who are considered "up-to-date". Such policies have been used historically to improve health outcomes, and they are currently being used as public health strategies to increase access to preventive health services in an effort to improve the nation's health.

Area-Level Variation and Human Papillomavirus Vaccination among Adolescents and Young Adults in the United States: A Systematic Review.

Understanding how human papillomavirus (HPV) vaccination coverage varies by geography can help to identify areas of need for prevention and control efforts. A systematic review of the literature was conducted using a combination of keywords (HPV vaccination, geography, neighborhoods, and sociodemographic factors) on Medline and Embase databases. Studies had to provide information on HPV vaccination by area-level variables, be conducted in the United States, and be published in English (analyzing data from January 2006 to February 2020). Conference abstracts and opinion pieces were excluded. Of 733 records identified, 25 were included for systematic review. Across studies, the average initiation rate was 40.5% (range, 6.3%-78.0%). The average rate of completion was 23.4% (range, 1.7%-55.2%). Geographic regions and area-level factors were associated with HPV vaccination, including zip code tabulation area-level poverty, urbanicity/rurality, racial/ethnic composition, and health service region characteristics. Only three studies utilized geospatial approaches. None accounted for geospatial-temporal associations. Individual-level and area-level factors and their interactions are important for characterizing HPV vaccination. Results demonstrate the need to move beyond existing multilevel methods and toward the adoption of geospatial approaches that allow for the mapping and detection of geographic areas with low HPV vaccination coverage.

Multi-morbidities are Not a Driving Factor for an Increase of COPD-Related 30-Day Readmission Risk.

Background and Objective: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. COPD is expensive to treat, whereas the quality of care is difficult to evaluate due to the high prevalence of multi-morbidity among COPD patients. In the US, the Hospital Readmissions Reduction Program (HRRP) was initiated by the Centers for Medicare and Medicaid Services to penalize hospitals for excessive 30-day readmission rates for six diseases, including COPD. This study examines the difference in 30-day readmission risk between COPD patients with and without comorbidities. Methods: In this retrospective cohort study, we used Cox regression to estimate the hazard ratio of 30-day readmission rates for COPD patients who had no comorbidity and those who had one, two or three, or four or more comorbidities. We controlled for individual, hospital and geographic factors. Data came from three sources: Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), Area Health Resources Files (AHRF) and the American Hospital Association's (AHA's) annual survey database for the year of 2013. Results: COPD patients with comorbidities were less likely to be readmitted within 30 days relative to patients without comorbidities (aHR from 0.84 to 0.87, p < 0.05). In a stratified analysis, female patients with one comorbidity had a lower risk of 30-day readmission compared to female patients without comorbidity (aHR = 0.80, p < 0.05). Patients with public insurance who had comorbidities were less likely to be readmitted within 30 days in comparison with those who had no comorbidity (aHR from 0.79 to 0.84, p < 0.05). Conclusion: COPD patients with comorbidities had a lower risk of 30-day readmission compared with patients without comorbidity. Future research could use a different study design to identify the effectiveness of the HRRP.

Outpatient facility volume, facility type, and the risk of serious colonoscopy-related adverse events in patients with comorbid conditions: a population-based study.

PURPOSE: Patients with a chronic comorbidity or multiple comorbidities are at much greater risk of serious colonoscopy-related gastrointestinal (GI) adverse events relative to patients with no comorbidity. It is important to identify outpatient facilities that can effectively and safely provide colonoscopy to complex patients. To address this need, the association between outpatient facilities' complex care volume and type (ambulatory surgery center (ASC) and hospital outpatient department (HOPD)) and the risks of serious GI adverse events in colonoscopy patients with single and multiple chronic comorbidities were examined. METHODS: Outpatient colonoscopies of 1,020,372 patients with single and multiple comorbidities were investigated, using a retrospective cohort study. Thirty-day hospitalizations due to colonic perforations and GI bleeding were examined. Ambulatory surgery and hospital discharge datasets from California, Florida, and New York for 2006-2009 were used. RESULTS: Higher complex care volume was associated with lower risks of adverse events in patients with comorbidities (OR 1.69; 95% CI [1.13, 2.54]). ASCs had higher risks of adverse events in patients with comorbidities relative to HOPDs (OR 2.85; 95% CI [2.40, 3.38]). Patients with single and multiple comorbid conditions, patients with systemic diseases, and complex patients of advanced age had higher risks of adverse events. CONCLUSIONS: Referring patients with single and multiple chronic comorbidities to facilities experienced in treating complex patients, or HOPDs, may reduce colonoscopy-related adverse events.

A taxonomy of hospitals participating in Medicare accountable care organizations.

BACKGROUND: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. PURPOSE: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. METHODOLOGY/APPROACH: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. RESULTS: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. CONCLUSION: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. PRACTICE IMPLICATIONS: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Factors associated with hospital participation in Centers for Medicare and Medicaid Services' Accountable Care Organization programs.

BACKGROUND: In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. PURPOSE: The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. METHODOLOGY: Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. RESULTS: Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. CONCLUSION: MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. PRACTICE IMPLICATIONS: Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

Preventable Hospital Admissions and 30-Day All-Cause Readmissions: Does Hospital Participation in Accountable Care Organizations Improve Quality of Care?

This study evaluates quality performance of hospitals participating in Medicare Shared Savings and Pioneer Accountable Care Organization (ACO) programs relative to nonparticipating hospitals. Overall, 198 ACO participating and 1210 propensity score matched, nonparticipating hospitals were examined in a difference-in-difference analysis, using data from 17 states in the years 2010-2013. The authors studied preventable hospitalizations for conditions sensitive to high-quality ambulatory care-chronic obstructive pulmonary disease (COPD) and asthma, chronic heart failure (CHF), complications of diabetes-and 30-day all-cause readmissions potentially influenced by hospital care. A decrease was found in preventable hospitalizations for COPD and asthma and for diabetes complications for ACO participating hospitals, but no significant differences for preventable CHF hospitalizations and 30-day readmissions. Mixed results may be attributable to insufficient incentives for ACO participating hospitals to decrease 30-day readmissions, whereas disease-focused initiatives may have a beneficial effect on preventable hospitalizations for COPD and asthma and complications of diabetes.

Analysis of Delays in Breast Cancer Treatment and Late-Stage Diagnosis in Kazakhstan

Objective: Although Kazakhstan has made significant investments to improve health and life expectancy of its population, high cancer rates persist, with breast cancer being the most prevalent type. Factors contributing to delays in treatment and late staging for breast cancer patients were assessed. Methods: A retrospective follow-up study with registry data identified 4,248 breast cancer patients in sixteen regions of Kazakhstan in 2014. We used logistic regressions to estimate (i) associations of treatment delays with patient demographics and cancer center regions; and (ii) associations of late-stage (III and IV) cancer diagnosis with patient demographics and cancer center regions, with and without controlling for treatment delays. Results: Breast cancer patients treated in regions located further away from Almaty City had higher risks of treatment delays. However, the risks of late-stage cancer diagnosis were greater for patients treated in Almaty City and those with treatment delays. Conclusion: The main driver of delayed treatment is cancer center region. Residents of Almaty City, a major urban area of Kazakhstan, may have a better access to a tertiary cancer center, resulting in less treatment delays. Referrals of sicker patients from neighboring regions to Almaty City for cancer treatment is likely to increase risks of late-stage diagnosis. New or upgraded cancer centers may reduce treatment delays, but their case-mix is likely to increase.

Patient Comorbidity and Serious Adverse Events after Outpatient Colonoscopy: Population-based Study From Three States, 2006 to 2009.

BACKGROUND AND OBJECTIVE: Serious GI adverse events in the outpatient setting were examined for patients with a full spectrum of comorbid conditions and combinations of multiple comorbidities. DESIGN: This is a retrospective follow-up study. SETTING: Ambulatory surgery and hospital discharge data sets from California, Florida, and New York, 2006 to 2009, were used. PATIENTS: The outpatient colonoscopies of 4,234,084 adults aged 19 to 85 and over and payers were examined. MAIN OUTCOME: Thirty-day hospitalizations due to colonic perforations and GI bleeding, measured as cumulative outcomes, were investigated. RESULTS: About 24% of patients undergoing outpatient colonoscopy had a comorbid condition. In comparison with patients without comorbidities, the adjusted risks of adverse events were greater for patients with several single comorbidities and combinations of multiple comorbid conditions. Elderly patients and those treated in freestanding Ambulatory Surgery Centers had higher odds of colonic perforations and GI bleeding than younger patients and patients treated in hospital outpatient departments. LIMITATION: The study was constrained by limitations inherent in administrative data. CONCLUSIONS: Given the large number of outpatient colonoscopies performed in the United States, these procedures should be provided with caution to patients with chronic and multiple comorbidities and the elderly, because these populations are associated with higher rates of colonic perforations and GI bleeding.

Diabetes management before and after cancer diagnosis: missed opportunity.

BACKGROUND: Few studies have examined the management of comorbidities in cancer patients. This study used population-based data to estimate the guideline concordance rates for diabetes management before and after cancer diagnosis and examined if diabetes management services among cancer patients was associated with characteristics of the hospital where the patient was treated. METHODS: We linked 2005-2009 Medicare claims data to information on 2,707 breast and colorectal cancers patients in state cancer registry files. Multivariate logistic regression models examined hospital characteristics associated with receipt of diabetes management care after cancer diagnosis. RESULTS: The rates of HbAlc testing, LDL-C testing, and retinal eye exam decreased from 72.7%, 79.6%, and 57.9% before cancer diagnosis to 58.3%, 69.5%, and 55.8% after diagnosis. The pre- and post-diagnosis diabetes management care was not significantly different by hospital characteristics in the bivariate analysis except for that the distance between residence and hospital was negatively related to retinal eye exam after diagnosis (P<0.05). The multivariate analysis did not identify any significant differences in diabetes management care after cancer diagnosis by hospital characteristics. CONCLUSIONS: Cancer patients received fewer diabetes management care after diagnosis than prior to diagnosis, even for those who were treated in large comprehensive centers. This may reflect a missed opportunity to connect diabetic cancer patients to diabetes care. This study provides benchmarks to measure improvements in comorbidity management among cancer patients.

Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations.

BACKGROUND: Implementation of accountable care organizations (ACOs) is currently underway, but there is limited empirical evidence on the merits of the ACO model. PURPOSE: The aim was to study the associations between delivery system characteristics and ACO competencies, including centralization strategies to manage organizations, hospital integration with physicians and outpatient facilities, health information technology, infrastructure to monitor community health and report quality, and risk-adjusted 30-day all-cause mortality and case-mixed-adjusted inpatient costs for the Medicare population. METHODOLOGY: Panel data (2006-2009) were assembled from Florida and multiple sources: inpatient hospital discharge, vital statistics, the American Hospital Association, the Healthcare Information and Management Systems Society, and other databases. We applied a panel study design, controlling for hospital and market characteristics. PRINCIPAL FINDINGS: Hospitals that were in centralized health systems or became more centralized over the study period had significantly larger reductions in mortality compared with hospitals that remained freestanding. Surprisingly, tightly integrated hospital-physician arrangements were associated with increased mortality; as such, hospitals may wish to proceed cautiously when developing specific types of alignment with local physician organizations. We observed no statistically significant differences in the growth rate of costs across hospitals in any of the health systems studied relative to freestanding hospitals. Although we observed quality improvement in some organizational types, these outcome improvements were not coupled with the additional desired objective of lower cost growth. This implies that additional changes not present during our study period, potentially changes in provider payment approaches, are essential for achieving the ACO objectives of higher quality of care at lower costs. PRACTICE IMPLICATIONS: Provider organizations implementing ACOs should consider centralizing service delivery as a viable strategy to improve quality of care, although the strategy did not result in lower cost growth.

Accountable care organizations in the USA: types, developments and challenges.

A historically fragmented U.S. health care system, where care has been delivered by multiple providers with little or no coordination, has led to increasing issues with access, cost, and quality. The Affordable Care Act included provisions to use Medicare, the U.S. near universal public coverage program for older adults, to broadly implement Accountable Care Organization (ACO) models with a triple aim of improving the experience of care, the health of populations, and reducing per capita costs. Private payers in the U.S. are also embracing ACO models. Various European countries are experimenting with similar reforms, particularly those in which coordinated (or integrated) care from a network of providers is reimbursed with bundled payments and/or shared savings. The challenges for these reforms remain formidable and include: (1) overcoming incentives for ACOs to engage in rationing and denial of care and taking on too much financial risk, (2) collecting meaningful data that capture quality and enable rewarding quality improvement and not just volume reduction, (3) creating incentives for ACOs that do not accept much risk to engage in prevention and health promotion, and (4) creating effective governance and IT structures that are patient-centered and integrate care.

Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events.

BACKGROUND: A use of polypectomy techniques by endoscopist specialty (primary care, surgery, and gastroenterology) and experience (volume), and associations with serious gastrointestinal adverse events, were examined. METHODS: A retrospective follow-up study with ambulatory surgery and hospital discharge datasets from Florida, 1999-2001, was used. Thirty-day hospitalizations due to colonic perforations and gastrointestinal bleeding were investigated for 323,585 patients. RESULTS: Primary care endoscopists and surgeons used hot biopsy forceps/ablation, while gastroenterologists provided snare polypectomy or complex colonoscopy. Low-volume endoscopists were more likely to use simpler rather than complex procedures. For hot forceps/ablation and snare polypectomy, low- and medium-volume endoscopists reported higher odds of adverse events. For complex colonoscopy, higher odds of adverse events were reported for primary care endoscopists (1.74 [95% CI, 1.18-2.56]) relative to gastroenterologists. CONCLUSIONS: Endoscopists regardless of specialty and experience can safely use cold biopsy forceps. For hot biopsy and snare polypectomy, low volume, but not specialty, contributed to increased odds of adverse events. For complex colonoscopy, primary care specialty, but not low volume, added to the odds of adverse events. Comparable outcomes were reported for surgeons and gastroenterologists. Cross-training and continuing medical education of primary care endoscopists in high-volume endoscopy settings are recommended for complex colonoscopy procedures.

Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications.

BACKGROUND AND OBJECTIVE: Serious GI adverse events in the outpatient setting were examined by polypectomy technique, endoscopist volume, and facility type (ambulatory surgery center and hospital outpatient department). DESIGN: Retrospective follow-up study. SETTING: Ambulatory surgery and hospital discharge datasets from Florida (1997-2004) were used. PATIENTS: A total of 2,315,126 outpatient colonoscopies performed in patients of all ages and payers were examined. MAIN OUTCOME: Thirty-day hospitalizations because of colonic perforations and GI bleeding, measured as cumulative and specific outcomes, were investigated. RESULTS: Compared with simple colonoscopy, the adjusted risks of cumulative adverse events were greater with the use of cold forceps (1.21 [95% CI, 1.01-1.44]), ablation (3.75 [95% CI, 2.97-4.72]), hot forceps (5.63 [95% CI, 4.97-6.39]), snares (7.75 [95% CI, 6.95-8.64]), or complex colonoscopy (8.83 [95% CI, 7.70-10.12]). Low-volume endoscopists had higher risks of adverse events (1.18 [95% CI, 1.07-1.30]). A higher risk of adverse events was associated with procedures performed in ambulatory surgery centers (1.27 [95% CI, 1.16-1.40]). Important findings were also reported for the analyses stratified by specific outcomes and procedures. LIMITATION: The study was constrained by limitations inherent in administrative data pertaining to a single state. CONCLUSIONS: As the complexity of polypectomy increases, a higher risk of adverse events is reported. Using lower risk procedures when clinically appropriate or referring patients to high-volume endoscopists can reduce the rates of perforations and GI bleeding. Given the large number of colonoscopies performed in the United States, it is critical that the rates of adverse events be considered when choosing procedures.

Examination of hospital characteristics and patient quality outcomes using four inpatient quality indicators and 30-day all-cause mortality.

The study objective was to examine hospital mortality outcomes and structure using 2008 patient-level discharges from general community hospitals. Discharges from Florida administrative files were merged to the state mortality registry. A cross-sectional analysis of inpatient mortality was conducted using Inpatient Quality Indicators (IQIs) for acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, pneumonia, and all-payer 30-day postdischarge mortality. Structural characteristics included bed size, volume, ownership, teaching status, and system affiliation. Outcomes were risk adjusted using 3M APR-DRG. Volume was inversely correlated with AMI, CHF, stroke, and 30-day mortality. Similarities and differences in the direction and magnitude of the relationship of structural characteristics to 30-day postdischarge and IQI mortality measures were observed. Hospital volume was inversely correlated with inpatient mortality outcomes. Other hospital characteristics were associated with some mortality outcomes. Further study is needed to understand the relationship between 30-day postdischarge mortality and hospital quality.